The Wisdom of Shadows: Chaos, Disintegration, and Psychic Growth in King Lear.

King Lear is a timeless exposition of humankind's attempt to find meaning amidst the ceaseless turbulence of existence. This entails navigating the disintegrating pulls of nature and harmful human action that exist alongside affiliative, life-promoting gestures shown toward one another. As the predictability and safety afforded by social and two-dimensional psychic constructs collapse, several characters in this play are forced to reckon with the untamed, less organized realms of the mind and natural world. This leads to movements toward psychic paralysis and disintegration, as well as toward growth and interpersonal healing, dynamics that hinge on the characters' internal structuring.

The environmental crisis and the film First Reformed: Paths to paralysis and change.

The natural world has always been integral to our existence; currently, we are compelled to reckon with our assumptions about this connection with mounting urgency. Individual reactions to the environment are influenced not only by the sociocultural surround, but also by one's internal world, particularly whether one's internal objects are felt to have been irreparably damaged or are potentially salvageable. Excessive guilt about destructive impulses can limit one's ability to recognize individual responsibility for the current situation without catastrophizing the weight of one's ecological footprint. Delusional solutions may be adopted, valorizing extreme forms of engagement. The film First Reformed illustrates what appear to be divergent approaches to the planet: ruthless exploitation by an industrialist versus an impassioned objection to destruction of the environment for economic gain. In this narrative, both are underpinned by a paranoid-schizoid mindset. We investigate the dynamics of this psychic state, which results in a constricted perception and an absence of constructive agency with respect to the environmental crisis. We present an alternative conceptualization of the natural world's place within a person's psychic equilibrium. We emphasize that a more integrated relationship with the environment can facilitate concerned, preservative action on behalf of the natural world and ourselves.

Acute Extrapyramidal Side Effects from Smoked Haloperidol.

INTRODUCTION: Haloperidol is a dopamine receptor antagonist used to treat patients with psychotic disorders. Especially at high doses, haloperidol carries a higher risk of extrapyramidal symptoms (EPS) compared to second-generation antipsychotics. Few cases of haloperidol misuse are found in the medical literature. Case Presentation. We describe a patient with schizophrenia who smoked marijuana mixed with crushed haloperidol tablets. After the smoking of cannabis and haloperidol, the patient presented to the emergency department (ED) with suicidal ideation, psychosis, and acute dystonia. With the administration of intramuscular diphenhydramine at the ED, the dystonia resolved in less than an hour. To our knowledge, this is the first report on haloperidol misuse by smoking. CONCLUSION: Clinicians should be aware that patients might misuse prescribed antipsychotics via unconventional routes, potentially combined with other substances.

Viral respiratory infections and psychosis: A review of the literature and the implications of COVID-19.

The historical association between respiratory infections and neuropsychiatric symptoms dates back centuries, with more recent literature highlighting a link between viral infections and schizophrenia. Maternal influenza infection during pregnancy has been associated with the development of schizophrenia in offspring. Viral infections in neonates, children, and adolescents have also been associated with later development of schizophrenia. Neuroinvasive and/or systemic infections are thought to increase risk for psychopathology via inflammatory mechanisms, particularly when exposure occurs during critical neurodevelopmental windows. Several human coronaviruses (HCoVs) have been associated with psychotic disorders and increasing reports of the neuropsychiatric manifestations of COVID-19 suggest it has neuroinvasive properties similar to those of other HCoVs. These properties, in conjunction with its ability to generate a massive inflammatory response, suggest that COVID-19 may also contribute to future psychopathology. This review will summarize the psychopathogenic mechanisms of viral infections and discuss the neuroinvasive and inflammatory properties of COVID-19 that could contribute to the development of psychotic disorders, with a focus on in utero, neonatal, and childhood exposure.

The Impact of Stress Within and Across Generations: Neuroscientific and Epigenetic Considerations.

ABSTRACT: The impact of stress and trauma on biological systems in humans can be substantial. They can result in epigenetic changes, accelerated brain development and sexual maturation, and predisposition to psychopathology. Such modifications may be accompanied by behavioral, emotional, and cognitive overtones during one's lifetime. Exposure during sensitive periods of neural development may lead to long-lasting effects that may not be affected by subsequent environmental interventions. The cumulative effects of life stressors in an individual may affect offspring's methylome makeup and epigenetic clocks, neurohormonal modulation and stress reactivity, and physiological and reproductive development. While offspring may suffer deleterious effects from parental stress and their own early-life adversity, these factors may also confer traits that prove beneficial and enhance fitness to their own environment. This article synthesizes the data on how stress shapes biological and behavioral dimensions, drawing from preclinical and human models. Advances in this field of knowledge should potentially allow for an improved understanding of how interventions may be increasingly tailored according to individual biomarkers and developmental history.

Current Understanding of the Neurobiology of Agitation.

INTRODUCTION: Managing agitation in the clinical setting is a challenge that many practitioners face regularly. Our evolving understanding of the etiological factors involved in aggressive acts has better informed our interventions through pharmacologic and behavioral strategies. This paper reviews the literature on the neurobiological underpinnings of aggressive behaviors, linking psychopathology with proposed mechanisms of action of psychiatric medications shown to be effective in mitigating agitation. METHODS: We performed a review of the extant literature using PubMed as a primary database. Investigation focused on neurobiology of agitation and its relation to the current evidence base for particular interventions. RESULTS: There are well-established pathways that can lead to increased autonomic response and the potential for violence. Psychopathology and substance-induced perceptual distortions may lead to magnification and overestimation of environmental threat, heightening the potential for aggression. Additional challenges have arisen with the advent of several novel drugs of abuse, many of which lead to atypical clinical presentations and which can elude standard drug screens. Our interventions still lean on the evidence base found in Project BETA (Best Practices in Evaluation and Treatment of Agitation). Although not a new drug and not included in the Project BETA guidelines, ketamine and its use are also discussed, given its unique pharmacology and potential benefits when other protocoled interventions have failed. CONCLUSION: Aggression can occur due to manifold reasons in the clinical setting. Having an informed understanding of the possible determinants of agitation can help with more tailored responses to individual patients, limiting the unnecessary use of medications or of interventions that could be deemed forceful.

The Genetic and Neural Circuitry Predictors of Benefit From Manualized or Open-Ended Psychotherapy.

OBJECTIVE: New technologies incorporating genetics and neuroimaging into psychiatric care offer the possibility of illuminating associations among genetic alleles, neural functioning, and patients' response to various psychotherapeutic modalities. In this review, the authors survey the literature on the emerging field of genetic predictors of psychotherapy response, particularly in relation to the 5-HTTLPR polymorphism and individual response to manualized psychotherapy. METHODS: The extant literature was reviewed, with PubMed serving as the primary database. RESULTS: Several polymorphisms have been linked with response or resistance to treatment. Given the number of studies assessing the relevance of the 5-HTTLPR polymorphism to treatment response, this review focuses on this genetic variation. CONCLUSIONS: Because individual genetic endowments may predict nonresponse to manualized treatment modalities, it may become possible to identify individuals who would benefit from insight-oriented, open-ended psychotherapy tailored to their individual distress tolerance levels, rather than from shorter manualized treatment.

Transdiagnostic Approach to Olfactory Reference Syndrome: Neurobiological Considerations.

Olfactory reference syndrome (ORS) describes a constellation of emotional and behavioral symptoms that cause clinically significant distress or impairment arising from the false belief that one is emitting an offensive odor. Despite cases of ORS reported throughout the world over the last century, our knowledge and understanding of ORS remain relatively poor because of the limited literature-mostly case studies and series, but no clinical trials. ORS continues to pose significant diagnostic challenges within our current frameworks of categorizing mental disorders, including the Diagnostic and Statistical Manual of Mental Disorders and International Classification of Diseases. We review the ORS literature and discuss diagnostic parallels and challenges of placing ORS within specific categories. We also review the current research on the neurocircuitry of olfaction and of disorders with potential clinical relevance to patients presenting with ORS. While no primary neuroscientific research has specifically investigated ORS, an overlapping circuitry has been implicated in the neurobiology of obsessive-compulsive, trauma and stressor, and psychotic spectrum disorders, suggesting that the phenomenology of ORS can best be understood through a dimensional, rather than categorical, approach.

Annotated Bibliography for Supervising Psychiatry Residents in Psychodynamic Psychotherapy.

OBJECTIVE: This paper sought to compile an annotated bibliography for the outpatient year of adult psychiatry residents, providing resources for a foundation in psychodynamic theory which can be utilized in supervision to aid in ongoing psychotherapeutic work. METHODS: In selecting the readings, the ACGME Milestones sub-competencies considered were (i) empathy and process, (ii) boundaries, (iii) alliance and provision of psychotherapies, (iv) seeking and providing supervision, and (v) knowledge of psychotherapy (theories, practice, and evidence base). Once the readings were selected, two authors independently reviewed the articles to determine which key sub-competencies each article addressed. Chance corrected agreement between the reviewers was assessed using the Cohen kappa statistic. The kappa for interrater agreement was 0.83. RESULTS: A list of 32 readings was compiled sequentially, allowing for theoretical concepts to be progressively built upon. The content of the papers aligned well with multiple sub-competencies in the medical knowledge (MK) and patient care (PC) domains. The bibliography allows for close examination of therapeutic frame; active listening and reflecting on the meaning of the therapist's interventions; transference and the use of countertransference as a diagnostic/therapeutic tool; defense mechanisms; patient pressures towards reenactment; theoretical viewpoints on therapeutic action (e.g., ego psychology, self-psychology, relational therapy, object relations, classical/modern Kleinian); and meaning of lateness, treatment breaks, and termination. CONCLUSIONS: This list serves as an ancillary resource which can augment discussions in therapy supervision, while also aiding in standardizing the minimal knowledge base achieved in psychodynamic theory.

Topiramate as Monotherapy or Adjunctive Treatment for Posttraumatic Stress Disorder: A Meta-Analysis.

Posttraumatic stress disorder (PTSD) is a chronic and debilitating condition for which clinicians sometimes turn to anticonvulsants as a treatment for symptoms. This study was a systematic review and meta-analysis of randomized controlled trials (RCT) that have assessed the efficacy of topiramate as monotherapy or adjunctive therapy, compared to placebo, for the treatment of PTSD in adults. Prescribers may be reluctant to turn to topiramate, given the commonly reported side effects of impaired cognition, sedation, fatigue, and headache. We searched PubMed, PsycInfo, and Cochrane Central databases for relevant trials. Five studies were identified as RCTs and thus met inclusion criteria; one additional nonpublished study was identified via phone contact with its authors. Of these six studies, one was excluded from the statistical meta-analysis due to its high dropout rate (16 of 40 participants). One of these studies was excluded from a stratified analysis of symptom types because this subscale data were unavailable.  For overall symptomatology, topiramate showed a medium, but not significant effect, standardized mean difference (SMD) = 0.55, p = .082. Topiramate showed a small and significant reduction of hyperarousal symptoms, SMD = 0.35, 95% CI [0.029, 0.689], p = .033. Topiramate did not significantly reduce reexperiencing symptoms, SMD = 0.29, 95% CI [-0.019, 0.597], p = .067, or avoidance symptoms, SMD = 0.20, 95% CI [-0.105, 0.509], p = .198. Results did not differ significantly between veteran and nonveteran subjects, or between topiramate as monotherapy and adjunctive therapy. Further studies on topiramate will clarify its role in PTSD treatment.

Corrigendum to "Epigenetic and Neural Circuitry Landscape of Psychotherapeutic Interventions".

[This corrects the article DOI: 10.1155/2017/5491812.].

Epigenetic and Neural Circuitry Landscape of Psychotherapeutic Interventions.

The science behind psychotherapy has garnered considerable interest, as objective measures are being developed to map the patient's subjective change over the course of treatment. Prenatal and early life influences have a lasting impact on how genes are expressed and the manner in which neural circuits are consolidated. Transgenerationally transmitted epigenetic markers as well as templates of enhanced thought flexibility versus evasion can be passed down from parent to child. This influences gene expression/repression (impacting neuroplasticity) and kindling of neurocircuitry which can perpetuate maladaptive cognitive processing seen in a number of psychiatric conditions. Importantly, genetic factors and the compounding effects of early life adversity do not inexorably lead to certain fated outcomes. The concepts of vulnerability and resilience are becoming more integrated into the framework of "differential susceptibility," speaking to how corrective environmental factors may promote epigenetic change and reconfigure neural templates, allowing for symptomatic improvement. Psychotherapy is one such factor, and this review will focus on our current knowledge of its epigenetic and neurocircuitry impact.

Self-Limited Kleptomania Symptoms as a Side Effect of Duloxetine.

Introduction. Impulse control disorders (ICDs) have been described as a side effect of dopamine agonists, frequently used in neurodegenerative conditions affecting the nigrostriatal pathway. Serotonin-norepinephrine reuptake inhibitors (e.g., duloxetine) have dose-dependent differential affinity for monoaminergic transporters, inhibiting the dopamine transporter at higher doses, thus increasing availability of synaptic dopamine, with the potential for similar impulse control side effects. Case Presentation. A 19-year-old Asian-American female with a history of depression developed new-onset stealing behaviors after an increase in her dose of duloxetine from 60 mg to 90 mg; she described these actions as "compulsive" and irresistible, later experiencing either relief or guilt, features compatible with an ICD. Her symptoms eventually subsided with continued use of 90 mg of duloxetine. Discussion. To the knowledge of the authors, this is the first report of a patient developing new-onset ICD behaviors after being placed on a higher dose of duloxetine, which can inhibit the dopamine transporter and cause difficulty with impulse control. The self-resolving nature of the symptoms may result from compensatory upregulation of dopamine transporters, increasing reuptake of dopamine. Asian populations may be at a higher risk due to the frequent occurrence of CYP2D6 polymorphisms, which decrease the conversion of duloxetine to its inactive metabolites.

Development of Tinnitus at a Low Dose of Sertraline: Clinical Course and Proposed Mechanisms.

Introduction. Serotonin is involved in filtering of auditory stimuli. Cochlear input is processed through complex interactions between serotonergic, glutamatergic, and GABAergic neurotransmitter systems. Options for treatment of tinnitus include selective serotonin reuptake inhibitors (SSRIs); however in rare instances this symptom may occur as a side effect of this class of medications. Case Presentation. A 50-year-old woman developed bilateral tinnitus after several weeks of being treated with sertraline 50 mg. She had been on a long-standing daily dose of aspirin 325 mg which had been discontinued shortly before starting sertraline. Medical work-up was negative for her symptom. Shortly after discontinuation of the medication, her tinnitus subsided completely. Discussion. Tinnitus is a rare side effect of sertraline and may be related to particular distribution of serotonin receptor subtypes within the auditory system, and serotonergic agents may reinforce or desensitize the activity of different receptors. Also, there may be a priming effect of salicylate agents on the auditory system, predisposing particular patients to be more sensitive to how auditory stimuli are processed.

Meta-analysis of the efficacy and safety of prazosin versus placebo for the treatment of nightmares and sleep disturbances in adults with posttraumatic stress disorder.

UNLABELLED: Although sleep disturbances occur commonly in patients with posttraumatic stress disorder (PTSD) and are associated with adverse outcomes and increased suicidality, they are often inadequately addressed by antidepressant medications. OBJECTIVE: This review aims to assess whether prazosin reduces nightmares, sleep disturbances, and illness severity in adults with PTSD. METHOD: Electronic databases (PubMed, PsycINFO) were searched in September 2014 for randomized controlled trials in adults. Search terms included posttraumatic stress disorder, prazosin, nightmares, and sleep disturbance. Included studies used prazosin and provided objective outcome data related to nightmares and/or sleep quality. RESULTS: Six studies (191 participants) met the criteria for inclusion. Prazosin was more effective than placebo in improving nightmares (standardized mean difference [SMD] = 1.022, 95% confidence interval [CI] [0.41, 1.62], p = .001), sleep quality (SMD = 0.93, 95% CI [-0.02, 1.88], p = .054; and SMD = 1.14, 95% CI [0.24, 2.03], p = .01), and illness severity (SMD = 1.20, 95% CI [0.79, 1.61], p = .001, with no significant effect on systolic (SMD = -0.01, 95% CI [-0.40, 0.37], p = .94) or diastolic (SMD = 0.30, 95% CI [-0.09, 0.68], p = .154) blood pressure. CONCLUSION: PTSD-related nightmares, sleep disturbances, and overall illness severity showed a significant response to treatment with prazosin. With careful dose titration, prazosin was well tolerated and had no significant sustained effect on blood pressure.

Acceptability of Mobile Phone Technology for Medication Adherence Interventions among HIV-Positive Patients at an Urban Clinic.

Mobile phone technology is increasingly used to overcome traditional barriers limiting access to care. The goal of this study was to evaluate access and willingness to use smart and mobile phone technology for promoting adherence among people attending an urban HIV clinic. One hundred consecutive HIV-positive patients attending an urban HIV outpatient clinic were surveyed. The questionnaire evaluated access to and utilization of mobile phones and willingness to use them to enhance adherence to HIV medication. The survey also included the CASE adherence index as a measure of adherence. The average age was 46.4 (SD = 9.2). The majority of participants were males (63%), black (93%), and Hispanic (11.4%) and reported earning less than $10,000 per year (67.3%). Most identified themselves as being current smokers (57%). The vast majority reported currently taking HAART (83.5%). Approximately half of the participants reported some difficulty with adherence (CASE < 10). Ninety-six percent reported owning a mobile phone. Among owners of mobile phones 47.4% reported currently owning more than one device. Over a quarter reported owning a smartphone. About 60% used their phones for texting and 1/3 used their phone to search the Internet. Nearly 70% reported that they would use a mobile device to help with HIV adherence. Those who reported being very likely or likely to use a mobile device to improve adherence were significantly more likely to use their phone daily (P = 0.03) and use their phone for text messages (P = 0.002). The vast majority of patients in an urban HIV clinic own mobile phones and would use them to enhance adherence interventions to HIV medication.

Exercise-induced anaphylaxis: a serious but preventable disorder.

UNLABELLED: Described for the first time approximately 30 years ago, exercise-induced anaphylaxis is a rare disorder characterized by development of a severe allergic response occurring after mild-to-strenuous physical activity. This disorder is especially important to recognize with the recent increase in physical activity and health fitness fads. A number of predisposing factors (eg, prior ingestion of particular food groups) linked to exercise-induced anaphylaxis has been outlined over the years. Mechanisms governing the condition are still being unveiled, and it is likely that one mechanism involves mast cell degranulation and inflammatory mediator generation resulting from the biochemical effects of exercise, sometimes in the presence of an ingested allergen such that wheat or shell fish. Clinical manifestations usually occur after around 10 minutes of exercise, and follow a specific sequence, starting with pruritis and widespread urticarial lesions, evolving into a more typical anaphylactic picture with respiratory distress and vascular collapse. Fatality is exceedingly rare, with only one documented case in the literature. There is an overlap of symptoms with other syndromes (such as systemic mastocytosis and cholinergic urticaria), and these should be remembered when establishing a differential. Treatment of exercise-induced anaphylaxis consists of immediate stabilization geared toward the anaphylactic response with epinephrine and anti histamines. The patient needs to be educated on preventive measures and equipped with an epinephrine autoinjector in the event of an emergency. Exercise-induced anaphylaxis remains a potentially serious disorder, and the health care provider should be aware of its clinical features and effective management strategies. KEYWORDS: anaphylaxis; allergy; exercise; hypotension; urticaria; asthma.